Tough Pill for Health Care?

Despite the correlation between health care’s fundamental principles and the tenets of green design, most health care organizations haven’t been aggressive in moving toward green buildings. They have been reluctant because of some unique challenges posed by incorporating green design principles into health care facilities. But a growing body of experience shows that those obstacles can be overcome by a mix of commitment, teamwork, pragmatism and financial savvy.

The timing is right for the health care industry to apply green principles. Health care construction is at a high level as the industry responds to changing demographics, medical needs and technology. This boom in construction represents an opportunity to create a generation of buildings with significantly smaller environmental footprints.

Although the term “green design” is widely used, it may be useful for health care facility executives to think of “greener” design. After all, is there any absolutely “green” building — except perhaps for one that is never built? “Greener” is useful for another reason. It recognizes that green design is not a one-size-fits-all solution. It is sometimes said that green design is simply good design. But if an organization is struggling to make payroll, is it good design to spend more of its limited capital in pursuit of green goals? Good green design has to support the goals of the organization.

The goals of the organization should be the starting point for any discussion of green strategies. The facility executive should be clear about why the organization is interested in building and operating a greener facility. There are three basic reasons for a facility executive to incorporate a green element into the design and operation of a health care building:

To save money. Some green design elements can reduce first cost, and many can reduce various operating costs. Most health care organizations will gravitate towards these kinds of measures first.
But using green design to save money can be a complex challenge. For example, many health care spaces are constantly being renewed and renovated. As a result, many mechanical engineers add capacity into their systems to allow for easier, more cost effective future renovations. Yet one of the reasons that green design is said not to cost more is that “right-sized” HVAC equipment is smaller and less expensive. In a health care facility, this argument is harder to make.

To promote a brand. The public is increasingly aware of environmental issues. As a result, some health care organizations are adopting green building principles as a way to brand themselves. Brand-building can be especially valuable for a health care organization because building occupants at health care facilities — patients, visitors and staff — may be more attuned to the health benefits of green buildings.

This issue can be particularly important to an organization that is designing a large building and facing a difficult planning process. For example, one way to make a dramatic environmental statement is to install solar panels in a prominent spot visible to visitors and occupants. Indeed, many facilities want to install photovoltaic panels as shading devices for windows even though this is by far the most expensive, least efficient way to deploy such a system.

Because the organization believes it is the right thing to do. Many organizations have adopted green design measures even if those particular measures don’t offer good short-term financial returns. In some cases, they extend the time horizon for calculating returns because they believe it is the right thing to do. The do-what’s-right argument has particular resonance in a health care environment, as the first principal of the practice of medicine is to do no harm. In a world where every carbon dioxide molecule emitted causes harm, there is a special role for health care organizations to play in the way they build and maintain their facilities.

Despite the benefits of green design, health care organizations face obstacles that other types of building owners don’t.

First cost is a barrier for pursuing green design in many kinds of facilities. However, health care facilities present a special challenge because of their thin margins and high first costs even without green measures. Hospitals in California can now cost $1,000 per square foot, and many health care organizations — pressed by insurers, doctors and regulations — simply cannot afford to invest additional capital in green design measures.

Another major obstacle to bringing greener building solutions into the health care environment is the mass of regulations that govern health care facilities. Because of the role they play in society, health care institutions are heavily regulated by both building codes and operational codes. Each regulation creates a barrier to trying new design strategies, including green strategies.

A third challenge is overcoming the lack of familiarity with green design measures and technologies. Health care organizations are conservative — with good reason. As a result, they tend to be reluctant to embrace new approaches until the new approaches have been pioneered and proven elsewhere. This attitude is especially prevalent in the infection control staff at many institutions. That’s easy to understand, given the serious risk of hospital-acquired infections.

Nevertheless, there are ways for health care organizations to overcome some of the obstacles to green design. Consider the following eight prescriptions for dealing with challenges.

Be clear on commitment and goals. Clarity on the rationale for green measures is essential to making informed decisions during the design process. Members of the design team may have varying levels of comfort with the facility executive’s goals, and the facility executive needs to make it clear to the team that the organization is willing to try new technology rather than sticking with tried and true approaches.

Consider benefits other than energy and water cost savings. Because it’s easier to obtain metrics to measure cost reductions for energy and water, facility executives may forget that these strategies may have other benefits as well that should not be overlooked. What’s more, investments in other measures may yield cost savings that are greater but more difficult to calculate than savings associated with energy and water.

Consider daylighting. Studies have suggested that daylighting can raise productivity and reduce medical errors, as well as saving energy.

Another good example is the use of automatic sensors for faucets. Many codes mandate use of hands-free devices in various clinical areas so that health care providers can wash their hands without touching the dirty faucet handles. Traditionally this has been done with foot-pedals. But it’s hard to clean around foot pedals, so they can cause infection-control problems. What’s more, they can be a maintenance headache, since they can be broken off when the floors are being cleaned.

Don’t get hung up on thresholds set in the Green Guide to Health Care or LEED (Leadership in Energy and Environmental Design) rating system unless obtaining these certifications is important to building the organization’s brand. Instead, focus on doing what is right for the project and the community. For example, if it isn’t feasible to reach a predetermined percentage of renewable energy, don’t completely eliminate renewables from consideration. Rather, the facility executive should determine how much renewable energy makes sense for the project.

Consider possible energy price fluctuations in return-on-investment analyses. It’s advisable to model sensitivity to price changes in different sources of energy. In other words, what happens to the payback for a certain measure if the price of different types of energy rises or falls? Having a record of this analysis will allow the facility executive to assess the risk of using a particular strategy when the choice comes down purely to payback. This will also give the facility executive a much better guide for responding to changing circumstances, without having to go back to re-study everything. In some cases, changes in energy prices lead to changes in the design. In other cases, energy-saving measures are not implemented, but the facility is designed to permit that strategy to be implemented once energy prices hit a certain level.

Do not abandon any green measure. Instead, think of adoption of green measures that aren’t used in the original design as being delayed. That is, even if a particular strategy is deemed not to be feasible at the time the facility is designed, the design should make it easy to accommodate that strategy in the future. This approach will make it easier, less expensive and more feasible to implement additional green measures later. Kaiser Permanente, the nation’s largest health maintenance organization, commonly refers to this strategy as an “enabling” approach.

Aggressively pursue third-party financing options. For example, a third party could buy, install, operate and maintain a photovoltaic farm. It would sell the power generated to the facility. This approach is especially beneficial to a non-profit organization. It allows the facility to share indirectly in tax benefits that are available to for-profits; to preserve capital; to implement green technologies the organization wants to use; to send a powerful message to the community about the organization’s values; and to fix the cost of some portion of the facility energy budget for a long time to come. The payback on this kind of approach is essentially instantaneous. It offers enormous advantages with very few downsides for a capital-constrained non-profit owner.

Use timing strategies to shift costs and take advantage of rebate opportunities when they arise. Rebates can help make green strategies economically feasible. But it isn’t always easy for a hospital to capture rebates while it is being built.

For one thing, individual rebates generally run for a specific period of time. Because designing, permitting and constructing a significant health care project is a long process, the rebates may expire before a hospital being designed and built can take advantage of them.

What’s more, rebates can’t always be used for a new facility.

To get around those problems, it may be worthwhile to implement some measures that qualify for rebates in the existing facility while the new one is being designed or constructed — and to do so in a way that makes it easy to transfer the systems installed in the existing facility into the new one, if the older facility is to be demolished. Doing so may allow a facility executive to take advantage of time-limited opportunities. It also makes it possible to use the current operating/capital budgets to cover the cost of measures that the new project might not otherwise be able to afford. And this approach makes it possible to improve the environmental performance of the facility sooner.

Consider upgrades to any existing facilities that will remain in place. For instance, investing $1 in improving an existing facility may yield higher benefits overall than investing the same $1 into enhancements of a new building. The goal should be to do the right thing instead of trying to package everything into the big new exciting project simply for the purpose of doing a green building.

At the end of the day, resistance to green design approaches may be more about culture than about technology. Health care facility executives and their teams need to recognize this. A good example of this principle is the potential for using sensor-operated faucets. Occupants sometimes object to the idea of using the faucets because they won’t be able to control the flow rate and temperature. But once occupants use the sensor-operated faucets for a while, they get used to them and the issue disappears.

Infection Control

Because the concerns of infection control specialists, often embodied in regulations, are so serious, they offer special challenges for implementing various kinds of strategies. However, they offer as many opportunities. Many strategies involving the use of greener materials inside the building will not only make the building more environmentally responsible, but will also provide a healthier environment for the patients, staff and visitors. Other concerns can only be overcome by careful study of proposed measures and even scientifically conducted studies. A recent study on ventilation strategies by Kaiser Permanente involved infection control specialists in the effort to determine the effects of various proposed alternatives.

Involving infection control professionals is extremely important in building a case for the safety of the proposed measures. Once the infection control staff has agreed that a particular green design element is safe, there is still the issue of regulations, which may block the use of green measures. For example, codes currently prohibit the use of displacement ventilation in hospitals, which could save energy. A research project is currently underway to examine the effect of displacement ventilation used with reduced air change rates on ventilation effectiveness, thermal comfort and infection control.

Regulators often have pathways for alternate means of complying with their regulations, but these are likely to offer additional hurdles to implementing newer, greener designs in health care buildings.

Despite these challenges, the health care industry offers many opportunities for implementing green building strategies. Health care organizations are steeped in an ethic of caring — caring for their patients, for their communities and for the greater good. Health care organizations can work towards all of these goals by pursuing green design. Overcoming the challenges to green design will require applying to buildings the same single-minded dedication that health care practitioners bring to their art.

ALL FOR ONEThe Case for Integrated Design

While it may be challenging to get all the parties in one place, the most sensible way to implement green strategies in a new facility is to use an integrated design approach.

The advantages are numerous. First, by gathering all the stakeholders in one location and hammering out a vision, expectations — and the cost — can be clearly understood by all parties involved.

“Everybody has to buy into this,” says Joe Kuspan, architectural designer with Karlsberger Associates. “You are only as strong as your weakest link.”

Two prerequisites in the Green Guide for Health Care call for integrated design. One reason is an attempt to reduce cost and complexity by focusing on green up front, says Adele Houghton, project manager, Green Guide for Health Care. “The later you start, the more of a cost premium there is,” Houghton says.

Holding one charette — as short, intense design meetings are often called— isn’t enough. Stakeholders need to meet throughout the process, says Alan Scott, principal with consulting firm Green Building Services. “Bringing them in and updating them on new opportunities and challenges and getting their feedback can be a very valuable experience,” he says.

On one project, the team decided to shift from using a photovoltaic array to improving indoor environmental quality because the urban site had a number of logistical challenges regarding PV use. Had the team not been meeting regularly, the decision may have been made to simply drop the PV array without switching focus to indoor environmental quality.

— Brandon Lorenz, senior editor

DISPLACEMENT VENTILATIONPursuing Gains in Energy Efficiency and Indoor Air Quality

Further advances in technology may pave the way for more efficiency gains without penalizing indoor air quality. Displacement ventilation, where air is discharged at floor level and vented through the ceiling, is one possibility.

Introducing the air at ground level reduces the amount of fan energy needed to move the air and eliminates the penalty that comes with cool air picking up the heat load from lighting systems and transferring it into a room. Improved circulation means fewer air changes are required. And cooling air in a displacement ventilation system also doesn’t need to be as cold and increases free cooling days, says Robin Guenther, principal for Guenther 5 Architects.

Such systems are already in use in Scandinavia, Guenther says. They haven’t yet found widespread use in acute care facilities in the United States because some infection control staff fear that air rising from the floor would pick up dirt and other contamination. Research is currently underway to examine the impact of displacement ventilation on comfort, ventilation and infection control.

Dell Children’s Medical Center in Austin, Texas, uses raised floor cooling in its office space, while some clinics have adopted displacement ventilation. In the case of one facility in New York, displacement ventilation and a radiant heating system combine to achieve significant savings, says Guenther.

—Brandon Lorenz

Energy Opportunities

Despite numerous challenges, facility executives have plenty of motivation to consider energy efficiency on their next health care project. Health care ranks second only to the food service industry in intensity of energy usage, according to the Department of Energy. And energy costs are soaring.

“It will not work for hospitals to take a position that they have to use that energy to save lives,” says Robin Guenther, principal for Guenther 5 Architects in New York. “Collectively in this industry we have to be smarter than that. We have to find a way to do both things.”

Given the rise in energy prices, CFOs are likely to be more receptive to projects such as upgrading old chillers or adding variable frequency drives, Guenther says.

“Within the next 12 months there is absolutely going to be far more discussion about climate change impacts from the use of fossil fuels and more pressure on the health care industry to do something about it,” she says.

—Brandon Lorenz

Walter Vernon is a principal with Mazzetti & Associates, a mechanical, electrical, plumbing and telecommunications consulting and engineering design firm headquartered in San Francisco. Vernon is an electrical engineer with more than 20 years of experience in the design and construction of health care facilities. He is co-coordinator of the Green Guide for Health Care and a member of Kaiser Permanente’s Environmental Stewardship Council.